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KISSI TOWN, Sierra Leone — Military choppers thunder over the slums. Nearly a thousand British soldiers are on the scene, ferrying supplies and hammering together new Ebola clinics. Crates of food and medicine are flowing into the port, and planeloads of experts seem to arrive every day — Ugandan doctors, Chinese epidemiologists, Australian logisticians, even an ambulance specialist from London.

But none of it was reaching Isatu Sesay, a sick teenager. She flipped on her left side, then her right, writhing on a foam mattress, moaning, grimacing, mumbling and squinching her eyes in agony as if she were being stabbed. Her family and neighbors called an Ebola hotline more than 35 times, desperate for an ambulance.

For three days straight, Isatu’s mother did not leave her post on the porch, face gaunt, arms slack, eyes fixed up the road toward the capital, Freetown, where the Ebola command center was less than 45 minutes away.

“This is nonsense,” said M.C. Kabia, coordinator of the volunteer Ebola task force in Isatu’s area. Help rarely came, he said, and people were quietly dying all over the place.

While health officials say they are making headway against the Ebola epidemic in neighboring Liberia, the disease is still raging in Sierra Leone, despite the big international push. In November alone, the World Health Organization has reported more than 1,800 new cases in this country, about three times as many as in Liberia, which until recently had been the center of the outbreak.

More than six weeks ago, international health officials conceded that they were overwhelmed in Sierra Leone and reluctantlyannounced a Plan B. Until enough hospital beds could be built here, they pledged to at least help families tend to their sick loved ones at home.

The health officials admitted Plan B was a major defeat, but said the approach would only be temporary and promised to supply basics like protective gloves, painkillers and rehydration salts.

Even that did not happen in Isatu’s case. Nobody brought her food. Nobody brought her any rehydration salts or Tylenol. No health workers ever talked to her about who she might have touched, which means anyone directly connected to her could now be walking through Freetown’s teeming streets, where — despite the government’s A.B.C. campaign, Avoid Body Contact — people continue to give high fives, hug and kiss in public.

Community volunteers said Isatu’s case was the norm, not the exception.

“We have a huge number of death cases,” said Mr. Kabia, the volunteer Ebola coordinator in Isatu’s area, Kissi Town, adding that residents rarely survived because of the slow response.

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On Freetown’s outskirts, burly youth are setting up roadblocks. The police are nowhere to be found. The young men barricade the road brandishing digital thermometers.CreditDaniel Berehulak for The New York Times

Discouraged, scared and furious, Sierra Leoneans are taking matters into their own hands. Laid-off teachers (all schools in this country are closed) race around on motorbikes, monitoring the sick. In some villages, informal isolation centers are popping up, with citizens quarantining one another, an incredibly dangerous ad hoc solution being performed without appropriate protection. (United Nations officials say this country is still short hundreds of thousands of protective suits.)

On Freetown’s outskirts, burly youth are setting up roadblocks. The police are nowhere to be found. The young men barricade the road, but instead of wielding weapons, they brandish infrared thermometers.

A passenger leaned out of the car while the ringleader scanned his head. 98.5. The posse then lifted the barricade, keeping anyone sick out of their neighborhood.

Fever is the scarlet letter of Ebola. Just about every important building in Freetown — hotels, banks, government offices — is now manned by a guard with an infrared thermometer and a bucket of diluted bleach for a mandatory hand wash.

But in the slums, it is a different story. In Kissi Town, an underserved area of dirt roads and dirty wells, the local Ebola task force said that more than 150 people had recently died of the virus, and that many had received no food, medicine or any other help.

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Ebola patients waited in the recovery area after testing negative for the virus at a treatment center in Freetown, Sierra Leone.CreditDaniel Berehulak for The New York Times

Stuck in her house, waiting for an ambulance, Isatu kept burning up. She was intensely nauseated, she said, but still able to walk a few steps, an important factor.

“If they walk in, their chances are good,” said Komba Songu M’Briwa, a doctor at an Ebola clinic. “If they have to be carried in, well …”

By last Friday morning, Isatu was not walking anywhere. She had become too weak to stand. Her chances were plummeting.

She curled up on the floor, her jeans splotched with dried black vomit. She was delirious, eyes bolted open, huge and blank. A shadow would cross the threshold and they would not even flicker.

The virus was moving faster than all the aid workers put together.

“I’ve called 10 times myself, ” said Abu Bakar Kamara, a community volunteer, as he paced the scratched dirt yard in front of Isatu’s house. “No response.”

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Health workers outside the high-risk area at the Hastings Ebola treatment unit in Freetown, the capital of Sierra Leone.CreditDaniel Berehulak for The New York Times

Sierra Leone has an elaborate Ebola response system — on paper. It starts with a call to 117, the toll-free number for central dispatch. A surveillance team is sent out, then an ambulance takes a patient to a holding center, then blood tests and a proper treatment center where the patient might receive intravenous fluids or other special care.

But the Ebola clinics do not have nearly enough beds, especially in Freetown, and an ambulance will not show up at a sick person’s house unless there is a bed somewhere for that patient. The government says it needs 3,000 beds nationwide but has fewer than half of that now.

Ambulances are hurtling across the country for hours to remote clinics in the east, where there are a few vacancies. The roads are horrendously bumpy; the jungle heat without reprieve. Many patients are dead on arrival.

Western officials are quick to add that even if all the resources were in the right place, that would not stop the virus.

“You can have as many helicopters, ships and kit here as you’d like,” said Lt. Colonel Matt Petersen, a British adviser. “But unless you change behavior, it’s not going to stop transmission.”

Public health professionals are beginning to look harder at Sierra Leone’s culture, which is dominated by secret men’s and women’s societies that have certain rituals, especially around burials. Many people here — just like in other cultures — believe that the afterlife is more important than this one. A proper burial, in which the body is touched and carefully washed, is the best way to ensure a soul reaches its destination.

It is not pure altruism, either. If burial traditions are not followed, people worry they may be haunted by a restless soul. But in a time of Ebola, handling corpses is extremely risky because they are highly infectious. Seventy percent of new cases here, Western officials said, are directly linked to traditional burials.

Kissi Town elders said that their outbreak started in early October after the funeral of a well-known society woman, as members of secret societies are called. Her name was Ya-Wullu, and she was known for handling dead bodies. After Ya-Wullu died from Ebola, an underling insisted on sleeping next to her corpse for three straight days. That second society woman then contracted Ebola too, and it shot through the community, elders said.

Neighboring Liberia has many of the same secret societies, but some anthropologists said that the Liberian government may have done a better job working with the leaders of secret societies to change burial practices, one possible reason Liberia’s Ebola crisis has been stabilizing.

Another issue are strikes. This week, burial workers in eastern Sierra Leone dragged corpses from a morgue and dumped them outside to protest delays in being paid. In Freetown last week, some surveillance workers — the emergency medical workers to suspected cases — refused to work, demanding back pay, which added to the problems of dispatching ambulances.

On Saturday afternoon, Isatu’s neighbors saw what they had been waiting for, rumbling up the road: a white truck with “Break the Chain” painted on the hood.

Help had finally arrived.

But this was not the Ebola team they had hoped for, evident by the way the workers slowly exited the vehicle and quietly suited up.

Isatu had died in the evening. The family said she was around 16 and loved a local game called balance ball.

The burial team moved fast, four white blurs through the door. Her mother seemed too exhausted to cry.

An hour later, all that remained of this teenage girl was a mound of dirt in a makeshift graveyard with a thin, flat stick poking out. The marker, placed in a growing forest of them, said “349, Isatu Sesay.”

There is a new important piece of information presented here “Seventy percent of new cases here, Western officials said, are directly linked to traditional burials.” If this is true it is a reasonable hypothesis to explain why this epidemic is so different from previous Ebola outbreaks. One previous estimate in the modeling for how the disease was spreading was that burial practices were about 17% of the basic reproductive number for Ebola in the region. However, if seventy percent of the transmission rate is actually due to religious burial practices, then without that factor the epidemic would end since the virus’s reproductive number would drop well below 1.
This estimate of the role of burial practices in spreading Ebola could explain the mysterious sudden drop on cases in Liberia as being the result of changed burial behavior. Also this would mean that when these burial practices mixed with the new introduction of Ebola then these religious burial practices then suddenly became severely counter survival. This is possibly the root cause of the epidemic and therefore may point to a rapid way to end the epidemic. Focus much more attention and assistance on burials and convince people to halt the burial practices that spread the disease and you could end the epidemic.

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One year ago, she died from complications in childbirth, a killer that every month takes twice as many lives as the entire Ebola epidemic. ... Many of these success stories were made possible through international development aid for maternal health, which increased steadily from 2010 to 2015.

Widow of Ebola Victim, Mother of Five Cries For Assistance March 18, 2018

Her story is probably more mind grappling than some of the famous stories told about the ugly impact left behind by the world's worst deadly Ebola virus outbreak in West Africa, including Liberia in 2014. Liberia became the worst affected with more than 5000 deaths. For Shianeh, every year Decoration ...